In 2004 almost 70% of the1.5 million United States nursing home residents stayed longer than six months and experienced higher levels of disability than previous nursing home populations. These long-stay residents pose a significant challenge to nursing homes'ability to deliver care that prevents excess disability. Restorative care programs are nursing rehabilitation activities implemented by nursing homes to prevent excess disability. Since the passage of the 1987 Omnibus Reconciliation Act nursing homes can receive additional reimbursement if they provide restorative care related to scheduled toileting, prompted voiding, walking, passive and active range of motion, bed mobility, transferring, dressing, grooming, eating, swallowing, communicating, and splint/brace/prosthesis care. In 2004, 67% of nursing homes provided specialized restorative care programs to 20% of long-stay residents based on this reimbursement policy. However, the decision to reimburse for these activities was based on expert clinical opinion at the time, with little research demonstrating their effectiveness in practice settings. Such knowledge is needed to justify reimbursement policies and to design and implement effective restorative care programs. The main objective of the proposed research is to identify if the currently reimbursed restorative care activities are effective at delaying the progression of disability in activities of daily living (ADLs) in older long-stay nursing home residents. This study will use a nationally representative sample of nursing home Minimum Data Set (MDS) data (N=5721 long-stay residents) linked to the 2004 National Nursing Home Survey. Mixed effect models that account for the nursing home environment and state reimbursement policies will be used to achieve the following aims: 1) describe the trajectory of change over 18 months in ADL disability among older long-stay nursing home residents and identify associated predisposing factors, pathologies, impairments, and functional limitations;2) describe patterns of restorative care participation over 18 months;and 3) determine if participation in restorative care activities has independent and/or synergistic effects on the trajectory of ADL disability after adjusting for predisposing factors, pathologies, impairments, and functional limitations. This study addresses important public health objectives to identify effective uses of rehabilitation resources and supports the long term goal of this research program which is to design effective nursing rehabilitation programs for long-stay nursing home residents. The findings will provide information useful for designing future clinical trials by identifying points in time where ADL disability accelerates, by identifying resident characteristics associated with accelerated progression of ADL disability, and by identifying which of the currently reimbursed restorative care activities delay ADL disability progression. This study is innovative because it is the first to use this nationally representative sample of MDS data available through the National Center for Health Statistics to analyze current restorative care practice. PUBLIC HEALTH RELEVANCE: The long term goal of this research is to implement nursing rehabilitation programs for long-stay nursing home residents that delay the progression of disability and optimize quality of life. The findings from the proposed study will provide information useful for designing effective restorative care programs by identifying points in time where ADL disability accelerates, by identifying resident characteristics associated with an accelerated progression of ADL disability, and by identifying which of the currently reimbursed restorative care activities delay ADL disability progression in long-stay older nursing home residents.